NESRI Media Center

Proscribing Prescriptions or Promoting Public Health? Opioid Treatment in Workers’ Comp

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Publication Date: 
August 10, 2018

The nation’s opioid crisis has reached epidemic proportions. More than 2 million people in the United States are now addicted to opioids or heroin, and in 2017 alone, 64,000 Americans died from drug overdoses—more than from car crashes or guns, more than died from AIDS at its peak, and more Americans than were killed in the Vietnam and Iraq Wars combined. Opioid addiction has helped put the nation’s life expectancy on track to fall for a third straight year, a backward slide virtually without precedent in the developed world. If things don’t improve, 650,000 more people could die of opioid or heroin overdoses in the next ten years. And it’s not just those who die who suffer: addiction is devastating entire families and communities.

Decades in the making, the opioid crisis is finally beginning to be taken seriously as a national priority: the House passed a set of 57 opioid bills in June, and the Senate is expected to follow suit. Yet far too little attention has been paid to the connection between opioids, dangerous jobs and workers’ compensation, despite research showing disproportionately high overdose fatality rates in occupations with the highest injury rates. This deficit has created space in which the pharmaceutical, workers’ compensation insurance and employers’ industries are capitalizing on the opioid crisis to chase profits by, yet again, pushing anti-worker legislation that is reshaping states’ workers’ comp systems. In this latest round of reforms, states are adopting statutes and regulations that further limit and tighten control over workers’ medical care rather than addressing worker safety and opioid addiction with the comprehensive, worker-centered public health approach the epidemic demands.
 
Workplace hazards and Big Pharma drive chronic pain and addiction
 
Workers in many industries contend with heavy lifting, repetitive motion, sedentary postures and other stressors that can lead to back injuries and other forms of musculoskeletal problems and chronic pain. Left untreated, chronic pain can be extremely debilitating, affecting not just people’s work, but also their home lives, their financial stability and their physical and mental health.
 
“When sustained over years, on-the-job injuries can give rise to chronically painful conditions, potentially resulting in a downward spiral of disability and poverty,” write public health scholars Nabarun Dasgupta, Leo Beletsky and Daniel Ciccarone in a paper in the American Journal of Public Health.

Workers suffering from painful injuries often have few options. As the Massachusetts Coalition for Occupational Safety and Health (MassCOSH) explains, “inadequate workers compensation systems and the fear of losing their job leads people to return to work before they are healed and to work in pain, depending on painkillers to get through their day, leading to addiction and overdose.”

This occurs, of course, in a context in which workers are systematically disempowered in the workplace and the economy. Workers often don’t have the power to fix the unsafe working conditions that cause their injuries, nor to make work and life adjustments that would allow them to manage their pain and return to health. (Workers in occupations in with lower rates of paid sick leave and higher job insecurity have higher rates of opioid overdoses, the Massachusetts Department of Public Health reported this week.) This is exacerbated by the fragmentation and biases of workers’ comp and the rest of the medical system, which tend to individualize and medicalize pain rather than pursuing systematic prevention and holistic occupational, physical and mental health treatment—strategies that must often include not only doctors and patients, but also a workers’ employer, co-workers and family members to be effective. In this context, the immediate pain relief offered by a pill can be the quickest, easiest solution for workers, doctors and employers alike.

With both workers and doctors under strain, in the 1990s drug reps began touting opioids as ‘miracle drugs’ for pain. They targeted much of their marketing at doctors serving patients with painful black lung disease in West Virginia and Kentucky, claiming that their extended-release formulas were less habit forming. By the end of the decade, pills had become a staple prescription for back pain and other common workplace injuries across the country.

As we now know, the low risk of addiction claimed by drug companies was wildly understated. When prescribed unchecked over the long term, opioids can be highly addictive. By 2015, according to the CDC, enough opioids were prescribed each year to medicate every adult in the country around the clock for three weeks and the nation was facing the worst addiction epidemic in our history. Yet drug makers, drug distributors and pharmacy chains haven't backed down. In 2016 they succeeded in lobbying Congress to pass, by unanimous consent in both houses, a bill that stripped the Drug Enforcement Agency of authority to intervene when companies ship dangerous amounts of opioids to local pharmacies.

Though opioid addiction extends far beyond injured workers, workers in dangerous industries like construction and fishing face a particularly high danger. National COSH’s opiate working group, the Massachusetts Department of Public Health, and peer-reviewed studies have all found higher rates of fatal opioid overdoses among workers in these occupations. National COSH also found that many workers who die of overdoses previously suffered work injuries. And geographically isolated workers including workers on fishing boats, in rural areas and in low-income communities of color face additional challenges because traveling to a clinic every day to receive a dose of methadone for drug treatment is often impossible.
 
Lobbying for false solutions
 
Since around 2000, increasing addiction and overdoses have attracted public attention, including the attention of insurance companies and employers’ associations. Seeking to cut the cost of prescriptions and reduce the potential role of addiction in driving long-term disability, these industries have pushed states to take action.
 
Over the last ten years state legislatures and the federal government have responded to lobbying by enacting new legislation to rein in opioid prescriptions. In 2011, for example, Texas introduced a closed formulary that requires workers’ comp insurers and self-insured employers to preauthorize workers’ prescriptions. That same year, Florida shut down “pill mills”—doctors’ offices dispensing large amounts of opioids—by banning physician dispensing of drugs. In 2012, Kentucky required providers to use its prescription drug monitoring program (PDMP) to monitor patients’ prescriptions across doctors and pharmacies before writing any opioid prescriptions for patients.
 
Such measures to cut off the supply of opioids would seem to make sense, but in practice most states have choked off prescriptions without doing much of anything to address the root causes of pain and addiction and without providing patients who are already suffering from drug dependency with effective treatments.
  
Drug formularies set what Dasgupta, Beletsky and Ciccarone describe as “arbitrary targets” that do not work for “patients who do not conform to clinically arbitrary expectations.” And as Beletsky explains in the Huffington Post, PDMPs are a tool that can do more harm than good if they’re employed in the wrong way. Too often when a patient is flagged for having too many prescriptions, their doctor’s only option is to withhold the prescription, “fire” the patient or call the police.

When tools like drug formularies and PDMPs are used to cut off medication or criminalize a patient rather than triggering a coordinated program of workplace safety, physical therapy, drug treatment, harm reduction and social and economic supports, they do not help workers with injuries or addiction. Instead they push patients out of the healthcare system and into the black market.

There is a long history of punishment and criminalization of addiction in the U.S., especially for poor people of color. In the 1980s and 1990s, the crack epidemic, which largely affected poor and working-class Black communities, was met with brutally punitive policing, prosecution and prison sentencing. Powder cocaine was also widely used at the time, but because it was more prevalent in wealthier White communities, officials took a far more lenient approach. Similarly, heroin addiction, which has historically been associated with poor people and people of color, has always been treated as more of a moral failing than addiction to prescription pills, which is frequently associated with celebrity overdoses and media tropes like painkiller-addicted soccer moms. Only as the perceived prevalence of opioids and heroin use among White people has increased have we begun to see a shift from criminalization toward a public health approach. We must still move much farther away from criminalizing addiction—by granting legal immunity to drug users who report an overdose, for example—but can only do so by directly contending with the historic and ongoing racial and class bias of the criminalization of addiction.

Rather than pushing people out of the healthcare system, monitoring and regulation of opioid prescriptions must be matched with workplace safety, comprehensive medical treatment and social supports to address patients’ pain and provide for their economic and psychological wellbeing. Unfortunately, in most states the industry-driven proposals that have been passed into law ignore the social and economic drivers of addiction, been warped by profit incentives and suffered from narrow, ideologically constrained thinking.
   
Pennsylvania, the latest state to become a battleground for such legislation, serves as an apt example of how this can play out. A recent bill proposing workers’ comp drug formularies (SB 936) sparked a heated debate, with the state’s unions, Democrats and medical and legal professionals warning that supporters’ promises of opioid prevention were nothing but a smokescreen for far-reaching attacks on injured workers’ medical and legal rights. As Lisa Benzie, president of the state trial lawyers group, explains, the bill’s overly broad wording threatened to give insurance companies decision-making powers that could limit treatment for injured workers beyond their drug regimens. Like many worker groups and advocates, the Pittsburgh firefighters union warned that the bill would take injured workers’ treatment “out of the hands of doctors and giv[e] the decision making power to insurance companies.” While democratic Governor Tom Wolf vetoed the bill at the end of April, it represents an ongoing legislative strategy being pushed more widely by the workers’ comp insurance industry.
 
A worker-centered public health approach to safety, pain and addiction prevention and treatment

An effective approach to preventing opioid addiction among workers must begin by preventing the root causes of injuries and pain that lead to addiction. As MassCOSH emphasizes in its 2018 Dying for Work report, safe, healthy workplaces and appropriate, comprehensive, timely treatment of workplace injuries are essential to reducing injured workers’ reliance on painkillers. 

Worker education is also an important factor. The Center for Promotion of Health in the New England Workplace is working to pilot a peer-training model on painkillers, addiction and how to advocate for proper medical treatment and work accommodations. The Center also emphasizes destigmatizing addiction, providing accessible recovery services and re-evaluating punitive workplace drug testing as crucial steps to help workers recover from opioid dependency.

When it comes to promoting effective evidence-based pain treatment, Washington State’s workers’ comp system provides a strong model. Washington’s Department of Labor, which runs the state’s public workers’ comp system, has worked in collaboration with other agencies to establish treatment guidelines for physicians and cross-agency prescription monitoring that guide doctors toward prescribing comprehensive pain management treatment and evidence-based addiction treatment rather than denying patients care.

Washington developed its approach in response to a 500% increase in opioid prescriptions in less than a decade. Its safe dosing guidelines, introduced in 2007 and updated in 2015, offer separate guidance to prevent addiction among patients receiving new prescriptions and to provide comprehensive treatment to patients already who are already dependent on opioids. In 2010, Washington added a good Samaritan law designed to help combat the risk of overdose for individuals suffering from addiction. The law gives legal immunity for drug possession to anyone seeking medical aid for an overdose and allows naloxone, a life-saving opioid antidote, to be prescribed preventatively to drug users and their friends and family members.

By targeting opioid use at multiple stages and emphasizing care and treatment rather than criminal consequences for addiction, Washington has effectively reversed opioid prescription and overdose rates. Its workers' comp system has seen significant decreases in the number of injured workers prescribed opioids or treated for opioid dependency.

While there is a clear public health consensus around the need for prevention and evidence-based treatment of opioid addiction, pro-worker solutions can only be widely implemented if labor, public health advocates and other allies work together to counter industries' anti-worker lobbying. National COSH has established an opiate workgroup comprised of community, academic and labor health and safety activists to conduct research and develop strategies. The group is in the process of building collaborations between National COSH's affiliates and university or state partners to investigate the connections between vulnerable workforces, occupational injury and opioid dependency. The group will host a webinar on September 20 from 2-3 pm, where you can learn more and find out how to get involved.

 

 

Read More on the Opioid Crisis
 

Origins, Impact and Solutions

The opioid epidemic, explained - Vox

How to stop the deadliest drug overdose crisis in American history - Vox

Inside a killer drug epidemic: A look at America's opioid crisis - New York Times

Opioid crisis: no easy fix to its social and economic determinants - American Journal of Public Health

A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and Lessons Learned - American Journal of Public Health

Opioid-related overdose deaths among Massachusetts workers- Mass. Dept. of Public Health

A public health approach to drug policy - Toronto Medical Officer of Health

Pharma's culpability

Politics of pain: Drugmakers fought state opioid limits amid crisis - The Center for Public Integrity

The family that built an empire of pain - New Yorker

Ex-DEA agent: Opioid crisis fueled by drug industry and Congress - CBS News with the Washington Post

Racial and Class Disparities in Treatment of Addiction

Opioid addiction knows no color but its treatment does - New York Times

Cashing in on despair - Dissent

Prescription Monitoring and Physician Guidance

As heroin deaths skyrocket prescription monitoring programs may do more harm - Huffington Post

CDC prescription guidelines - CDC

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